While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?
Palpate for pedal pulses.
Turn the patient every three hours.
Document the stage 1 pressure injury.
Elevate bilateral heels.
The Correct Answer is A
A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.
B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.
C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.
D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "This new room has negative pressure and does six to twelve air changes an hour and disposes the air outside to reduce the infection potential in other patients. I also have to wear this surgical mask."
While this provides technical information, the surgical mask part is incorrect; the nurse should wear an N95 respirator, not a surgical mask.
B. "It sounds like you have some questions about your new diagnosis. What are you most concerned about?"
While this is a therapeutic communication technique, it does not directly answer the patient's question about airborne precautions.
C. "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it."
This statement provides disease information but does not explain why airborne isolation is necessary.
D. "Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."
This provides a concise and accurate explanation of airborne precautions in terms the patient can understand.
Correct Answer is C
Explanation
A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.
B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.
C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.
D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.
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